Two years after releasing the white paper, and six years since enactment of the HITECH Act[2], the question remains. There is inconclusive evidence that the program has achieved its goals of increasing efficiency, reducing costs, and improving the quality of care.

We have been candid about the key reason for the lackluster performance of this stimulus program: the lack of progress toward interoperability. Countless electronic health record vendors, hospital leaders, physicians, researchers, and thought leaders have told us time and again that interoperability is necessary to achieve the promise of a more efficient health system for patients, providers, and taxpayers.

We were pleased that the Office of the National Coordinator for Health Information Technology (ONC) recognizes the concern of hospitals, providers, patients, and other stakeholders, and recently released a draft roadmap for interoperability. In it, ONC proposes[6] to work with stakeholders to develop minimal standards for the safe and secure exchange of EHRs. We appreciate ONC’s efforts to identify the steps necessary to achieve true interoperability of EHRs, but we are concerned that the draft speaks in generalities and does not address all of the concerns raised about interoperability in the REBOOT report.

The ONC roadmap provides a framework for responsibility, governance, and accountability in regard to the future development and implementation of interoperable EHRs. But instead of offering specific objectives, deadlines, and action items, ONC’s roadmap falls short on the nitty gritty technology specifics that vendors and providers need when developing IT products. We are left with many outstanding questions about how to achieve interoperability and how to address the cost, oversight, privacy, and sustainability of the meaningful use program.

Interoperability

A truly interoperable health system in local communities and across the country will enable physicians, hospitals, and other health care providers to seamlessly share patient information, such as medical histories or diagnostic tests, through a secure network. Sharing this information should improve care and reduce costs by allowing physicians to better coordinate care. For example, health information exchange between providers should prevent duplicative tests and harmful drug interactions.

After spending $28 billion[7] so far of the $35 billion total taxpayer investment, significant progress toward interoperability has been elusive. Stage 1 of the meaningful use program failed to include any meaningful health information exchange requirements, and lacked a vision to achieve interoperability. Instead, Stage 1 incentivized the widespread adoption of EHR systems that providers now say are difficult to use and lack the ability to exchange information without costly upgrades.

We are now well into Stage 2 of the Meaningful Use program and providers are struggling to meet even modest health information exchange requirements. According to a report[8] released by the Centers for Medicare and Medicaid Services (CMS) on February 10, 2015, only 131,905 out of more than 500,000—or roughly 25 percent—of eligible medical providers and hospitals had attested to either Stage 1 or Stage 2 for 2014. Responding to stakeholder feedback, CMS allowed more flexibility[9] to providers to meet Stage 2 requirements.

By remaining in listening mode, ONC proposed high-level goals for how to achieve interoperability, like building on existing infrastructure and empowering individuals, but the roadmap fails to outline real and actionable next steps. It is not enough for ONC to identify factors it believes are important. It must also delineate how it will find specific solutions to these concerns. The HITECH Act was clear: ONC is supposed to certify EHRs that can meet the program requirements for the meaningful use of EHRs.

Meaningful use of EHRs is supposed to deliver value to patients and physicians, but instead we have reports that have shown[10] that ONC certified products fail to deliver the value of easily exchangeable health information to better coordinate care. They are also incredibly expensive with no guarantee that providers purchasing certified products will achieve the Meaningful Use program requirements.

Indeed, through the ONC certification program, ONC has had the ability to achieve interoperability, but instead ONC is still struggling. Nothing makes this point more clear than this fact: Stage 2 meaningful use was promised to be the stage when health providers were interoperable yet we are well into Stage 2 and ONC is just now releasing its vision for interoperability with a high level roadmap.

We have seen many high-level documents on interoperability: the JASON reports, the Health IT Policy and Standards Committees’ reports, the Connecting Health and Care for the Nation: A 10-Year Vision to Achieve an Interoperable Health IT Infrastructure report, and the Federal Health IT Strategic Plan 2015-2020 report. All of these reports, as well as the ONC’s latest roadmap, are missing the same thing: practical and actionable steps to ensure a proper return on the American people’s investment.

Increasing Costs

In 2009, the Congressional Budget Office (CBO) estimated[2] that fully integrated interoperability would save the Medicaid and Medicare programs $12.5 billion through 2019. These savings have yet to materialize and with 50 percent of doctors unable to meet current program requirements, it is unlikely that taxpayers will see these savings [11]in the near future. Moreover, the number one complaint we hear from providers is the unexpected costs of maintaining and upgrading their systems.

ONC does not describe how it will determine the costs associated with the adoption of expanding interoperable platforms. Nor does ONC explain how it would evaluate cost or incorporate cost control into the development and scaling of interoperability. Provider concerns about the cost of complying with the program should be addressed in the roadmap.

We appreciate the notion[12] that as new models of care begin to reward providers for outcomes, changing incentives will reward interoperability. We agree. However, we live in the aftermath of the HITECH Act, where to date $28 billion have not resulted in significant improvements to clinical care coordination or quality. Without concrete immediate and long-term steps, tied into accurate, usable (and collectable) performance measures, we will continue to see a meager return on investment.

Lack of Oversight

One way to improve oversight of the program is to put in place measures to gauge success. ONC appears to be taking a step in the right direction by describing seven different lenses to measure and evaluate the quantity and quality of information flow within interoperable systems, such as who is exchanging information, and where and what type of information is being exchanged. However, without specific performance goals for each type of measurement, it is unclear how ONC will measure success. In addition to defining these metrics, effective oversight includes describing how the metrics will be collected, analyzed, reported, and used for decision making.

The fiscal year 2015 Omnibus Appropriations Act required ONC to issue a report on information blocking — the practice that EHR vendors, and sometimes hospitals and physicians, use to prevent electronic information exchange as a way to gain a competitive advantage in the health care marketplace. The report will give Congress a better understanding of the extent to which information blocking happens and a comprehensive strategy on how to address it. It will also provide a good example of how ONC exercises its oversight responsibility.

Patient Privacy at Risk

The security of patients’ personal health information in EHR systems is a real and immediate concern to us. According to a warning the Federal Bureau of Investigation (FBI) issued to health care providers in April 2014, the health care industry has the highest volume of cyber threats and the slowest response time. The industry “is not as resilient to cyber intrusions compared to the financial and retail sectors, therefore the possibility of increased cyber intrusions is likely,” the FBI stated[13]. Unlike a credit card number, the information contained in a patient’s health record is impossible to reissue. Health records contain financial records, personal information, medical history, and family contacts — enough information to steal and build a full identity or use for valuable research purposes.

The ONC roadmap describes collaboration across several government agencies to accomplish their security goals. It says the Department of Health and Human Services will work with the Office of Civil Rights and industry to develop and propose a uniform approach to developing and enforcing cybersecurity in health care in concert with enforcement of HIPAA Rules.

However, the roadmap lacks clear, obtainable goals regarding security requirements and implementation. Additionally, the costs for our future security infrastructure are unknown, as well as who will pay for it. As new cyber threats emerge every day, this administration must answer these questions quickly. The recent hack on a major health insurer that compromised personal information, including Social Security numbers and health histories, of tens of millions of Americans highlights the urgent need for an appropriate framework to protect patient privacy.

Program Sustainability

The long-term sustainability of EHR systems remains one of the biggest unknowns. ONC’s roadmap is surprisingly silent on this topic, which is stunning considering that there is only $7 billion in funding left from the HITECH Act. While the President’s Budget does request a significant increase in funding for ONC, the administration seems to ignore the reality that taxpayers have already committed billions of dollars toward a goal that is still vague.

According to ONC[14], implementing EHR systems range from $15,000 to $70,000 per provider. According to a September 2014 IBIS World Report [15]on EHRs, nearly 45 percent of physicians from the national survey reported spending more than $100,000 on a system. About 77 percent of the largest practices spent nearly $200,000 on their systems. However, even these estimates fail to consider upgrade and vendor costs associated with running these systems. Numerous stakeholders have stated that one large obstacle to interoperability and sustainability is the cost[16] of sharing data among different vendors.

ONC envisioned[17] the State Health Information Exchange Program would help facilitate this exchange, and taxpayers spent over $500 million on this effort. Yet, the program has failed to provide a long-term approach to information exchange. According to a RAND Study[18] published in December 2014, only about 25 percent of the nation’s health information exchanges are considered financially stable by those who run them. These programs’ inability to sustain operations without federal funding triggers more questions. With HITECH Act funding dwindling, we fear that time is running out for ONC to make meaningful advancements toward interoperability.

Looking Ahead

In listening to the concerns from EHR vendors and EHR users from across the care continuum, ONC has taken an important turn under the leadership of Dr. Karen DeSalvo. The previous ONC leadership did not understand the difficulty and enormity of creating government-approved products in a market that struggled to exist before government incentives arrived.

As a result, our nation’s health care providers are stuck with the huge cost of unwieldy systems trying to conform to government mandates. They are stuck adopting EHR systems which don’t fit into their established workflows. And if they actually want to share their patients’ data, they are stuck with even more costs imposed by vendors.

At the center of all this is the patient who must sit quietly in the exam room looking at her physician use a computer instead of directly talking with her, who likely has seen no better access to her own data, and who is struggling to understand why her doctor has such a difficult time getting her lab results.

That the ONC roadmap recognizes these concerns is a welcome change. High-level ideas are important, but we are concerned that without specific requirements and action items, we will not advance towards the goal of improving health care coordination and patient care, which was the intent of the HITECH Act.

In July 2012, FDA released a proposed rule to create a UDI system to track medical devices. Such a system would allow FDA officials to electronically track medical tools and promptly recall any devices that could jeopardize patient safety.

FDA in September 2012 issued a report that outlined the agency’s approach to improving its post-market surveillance system for medical devices, including the creation of a UDI system (iHealthBeat, 9/3).

Details of Report

The report aims to advise providers on how to adopt and integrate UDIs to improve patient safety, research and analytics, according to EHR Intelligence.

In the report, the authors recommend:
•Conducting studies to showcase the benefits of UDI use;
•Including UDIs in claims details for high-risk, implantable devices;
•Incorporating UDIs into EHR systems and personal health records;
•Increasing outreach about UDIs through collaborations between advocacy groups, FDA and providers; and
•Using UDIs across supply chain, clinical and revenue cycle processes to obtain the highest return on investment.

The authors also recommend including UDIs in Stage 3 requirements of the meaningful use program. Under the 2009 economic stimulus package, health care providers who demonstrate meaningful use of certified EHRs can qualify for Medicaid and Medicare incentive payments (Bresnick, EHR Intelligence, 12/5).

A flood of new health care IT companies has been pouring into the U.S. health care market. The cause of this torrent: the recognition that as market and regulatory forces alter incentives in health care, IT companies will play a powerful role in combating the overemployment and declining productivity that has plagued this industry and in helping providers improve the quality of care.

The dam broke in September 2007, when Athenahealth went public, the price of its shares jumping by 97% on the first day. Since then, the company’s value has risen to $5 billion. Athenahealth proved to entrepreneurs, software engineers, and investors that the health care sector is fertile ground for creating large technology-services companies that use a subscription-based business model to offer software as a service (SaaS).

Despite its size and growth rate, the health care sector was long considered an impenetrable, or at least an unattractive, target for IT innovation — the entrepreneurial equivalent of Siberia. Athenahealth broke the ice by proving that it could sell SaaS efficiently to small physician businesses, get doctors to accept off-premises software, and achieve the ratios of customer-acquisition costs to long-term value that other sectors already enjoy.

As Athenahealth accomplished its goals, several larger forces have dramatically widened the scope of opportunity in the sector:
•The Great Recession led to a loss of 8.8 million U.S. jobs and big declines in demand throughout the economy (including health care services) — yet health care employment grew by 7.2%. That reality increased awareness that a decline in labor productivity was driving much of the excessive spending in health care.
•The American Recovery and Reinvestment Act of 2009 included the Health Information Technology for Economic and Clinical Health (HITECH) Act, a $25.9 billion program to give doctors and hospitals incentives to adopt electronic health records. EHR adoption has now grown to nearly 80% of office-based physicians and 60% of hospitals, fueling many successful software start-ups, such as ZocDoc, Health Catalyst, and Practice Fusion.
•The Affordable Care Act (ACA) requires that an enormous amount of data on cost and quality be made freely available. In addition, digital health applications, mobile phones, and wearable sensors, as well as breakthroughs in genomics, are creating truly big data sets in health care. These data contribute to greater market efficiency, more consumer-oriented products and services, and clinical care that is evidence-based and personalized.
•The ACA has led to a proliferation of risk-based (rather than fee-for-service) payment models. For example, providers in accountable care organizations are rewarded for generating annual savings, and providers who use bundled payments get a fixed budget for an end-to-end course of treatment. Effectively responding to these changing economic incentives will increase reliance on software that helps providers manage population risk, understand costs and trends, and engage patients.

These macro-level developments set the stage for other SaaS companies to follow Athenahealth’s lead in enormously improving labor productivity and quality of care.

Within the next decade, software tools will eliminate thousands, perhaps millions, of jobs in hospitals, insurance companies, insurance brokerages, and human resources departments. Not the jobs of people who actually provide care — but those of administrative middlemen, whose dead weight contributes to economic loss. Here are five examples:

1.Digital insurance markets, combined with ACA-enacted regulatory changes such as guaranteed issue and community rating, make it possible to price and sell health plans to anyone immediately. These developments will decimate the armies of brokers who act as intermediaries between customers and insurance services.

2.Price transparency, digital insurance products, and tools such as reference pricing make it possible to generate an exact price and instantly collect payment for a health care service. As a result, revenue cycle managers in hospitals and claims adjudicators in insurance companies will be displaced.

3.The inevitable shift to the cloud will render obsolete the costly, insecure data centers that most doctors and hospitals are now building, staffing, and running.

4.Adopting self-serve mobile applications will eliminate the forms, faxes, and excess staffing at many call centers, thereby improving satisfaction for everyone in the process.

5.Centralized clearinghouses that share information across organizations and state lines will eventually replace the byzantine, paper-based process of credentialing doctors, tracking continuing medical education, and keeping licenses up-to-date. That means smaller staffs in hospitals’ medical affairs divisions, health plans, medical boards, and state and local health departments.

Given that wages account for 56% of all health care spending, improvements in labor productivity could generate enormous value. Simply reducing administrative costs could yield an estimated $250 billion in savings per year.

As compelling as the prospective labor efficiencies are, the benefits of SaaS extend beyond direct labor costs. Easier access to data on physician quality, specialization, and adherence to evidence-based care will better match patients with doctors who provide high-quality, efficient services, thereby averting health complications for their patients. Moreover, software can help bring relevant clinical guidelines and personalized risk scores to patients and clinicians as they improve care plans, engage in shared decision making, and avoid duplicative services. Such efficiencies will, in turn, enhance how patients perceive and experience the care they receive. SaaS companies can trumpet all of these advantages, not just the employment savings they yield.

To seize on the new opportunities in the health care sector, SaaS companies can take these steps:
•Attack economic inefficiencies in order to generate immediate, tangible customer return on investment. Witness how Castlight Health’s transparency tools are generating annual savings for employers and employees. And be clear about the source of the ROI, given that in most cases the revenue comes from another health care stakeholder who may be able to undermine the business.
•Focus on building in network effects so that improvements made by one user enhance the product’s value for current and future users, just as Athenahealth does when it rapidly disseminates changes in payment rules at one provider to all other providers. Most SaaS businesses in health care IT cannot protect their intellectual property; so it is important to continually augment the value of the product to achieve scale.
•Use software-enabled service models, rather than pure SaaS. For example, Grand Rounds’ software not only recommends an expert doctor for a patient but also collects, organizes, digitizes, and summarizes the patient’s records — and then books the appointment for the patient. In effect, the software makes it easier for patients to adhere to high-quality, cost-effective care, thereby enhancing the overall ROI for the product.

It took Athenahealth a decade, from 1997 to 2007, to go public on the strength of its SaaS model. It took Castlight Health only six years, from 2008 to 2014, to do the same. Now an array of highly valued healthcare SaaS companies, each worth more than $100 million, is emerging. They include Zenefits, Grand Rounds, Doctor on Demand, Omada Health, Health Catalyst, Doximity, and Evolent Health. Indeed, Zenefits is one of the fastest-growing SaaS companies ever, regardless of industry, surpassing $500 million in enterprise value in its first year.

The success of SaaS companies in health care is thanks, in part, to an influx of leaders from other sectors. They bring with them teams of technical talent that deliver consumer and enterprise software faster, better, and more cheaply than many legacy health care IT companies can do. Witness ZocDoc, founded by first-time entrepreneurs from McKinsey; Grand Rounds, founded by Owen Tripp, who cofounded Reputation.com; Zenefits, founded by Parker Conrad, who cofounded SigFig; and Doctor on Demand, founded by Adam Jackson, who cofounded Driverside (just to name a few). This type of cross-pollination is an essential ingredient of innovative change.

The barriers between health care IT companies and IT in other industries are clearly coming down, and we expect the number of sector disruptions and billion-dollar companies to swell. As each innovation wave generates more data, disruption-cycle times will shorten, thereby forcing all players in the health care ecosystem to address inefficiency as they compete on quality and value creation. Those who fail to act will be washed away by the tide that lifts all other boats to greater productivity.

Interoperability and Meaningful Use efforts need to be aligned with other healthcare regulatory and industry initiatives, according to the eHealth Initiative, which on Thursday unveiled its 2020 roadmap for transforming health IT.

The roadmap, which eHealth Initiative CEO Jennfier Covich Bordenick calls “a framework for discussion about core technology issues,” includes priorities for three areas: business and clinical motivators, interoperability and data access and use. In particular, she says, the private sector’s role must grow in order for health IT to move forward.

“We are heading into a world where healthcare data needs to be exchanged, shared and analyzed, not simply pushed from place to place,” Bordenick says in the document. “Similarly, we are developing a 2020 roadmap that requires sharing, analysis and above all, collaboration.”

Compared to the Office of the National Coordinator for Health IT’s interoperability roadmap, which will be available for public comment in January, the eHealth Initiative calls its plan “much broader,” but acknowledges that there is overlap between the two efforts to ensure synchronicity.

The roadmap specifically calls for an extension of time between Stages 2 and 3 of the Meaningful Use program, and also says that compliance with ICD-10 by next October is mandatory. The adoption of standards and open architecture also is encouraged for interoperability to evolve, as is the adoption of “approaches reflecting cross-industry IT trends” such as REST and FHIR.

Additionally, the roadmap says that Meaningful Use, despite its importance, is not a “sufficient lever” to ensure interoperability throughout healthcare.

A survey published in September from Premier and the eHealth Initiative concluded that poor interoperability is a significant barrier for accountable care organization success.

“We envision a high-performing healthcare system centered around the patient, where all those engaged in patient care are linked together in a secure and interoperable environment,” the roadmap says.

The roadmap also looks to kick-start conversations about how to solve several privacy and security challenges in healthcare today, including data security, appropriate data sharing, granular data control, data provenance and data matching.

Why do so many seemingly great technologies fail to penetrate the health care system?

I hope the following five answers shed some light on the realities of technology adoption in health care.

1. Many new technologies don’t address the real problem

Tech entrepreneurs often take a backward approach to invention. They start by discovering a nifty technology. Later, they figure out how people can use it.

This technique often teaches entrepreneurs a tough lesson: Technology is worth nothing if it doesn’t solve an important problem or improve lives.

Alan Cooper, considered by many to be the father of modern user experience design (UXD), said the ideal approach is “goal directed.”

Meaning, innovators should start with the goals of the end-user. The solutions come next. When the order is reversed, the results usually disappoint.

As an example, the health care world recently has become enthralled with wearable devices. Many of these devices help solve the problem of what gift to give a loved one during the holidays. But few of these devices solve major health problems.

These wristbands, sensors, headsets and even “smart clothes” can obtain and transmit huge amounts of data on anything from heart rhythms to blood pressure. But there’s little evidence those wearing them overcome abnormal heart rhythms or elevated blood pressures better than those who don’t.

Besides, physicians don’t want all that data anyway. They find it overwhelming, redundant and unlikely to make a clinical difference.

Physicians would love a tool that truly helps patients better manage their diet, exercise and stress levels. Many applications available today claim to modify behavior through alerts, reminders and real-time feedback, but few have demonstrated measurable success.

Entrepreneurs hoping to make a positive impact on our health should focus on helping patients avoid chronic diseases and manage health problems when they arise. And they would be wise to do this using technology that already exists while developing solutions that are easy to use and inexpensive to buy.

Apps using new, complex or expensive technologies will face an uphill battle for adoption.

2. No one wants to pay for new technologies

Creating an innovative tool or app that can help doctors and patients isn’t enough. These products must also be monetized.

In health care, that proves difficult.

Patients, physicians, hospitals and insurance companies long for the benefits and value of new technology. However, each thinks someone else should pay for it.

Further, entrepreneurs must understand the financial difficulties inherent in health care’s current fee-for-service payment model. Doctors and hospitals will be slow to embrace any technology that lowers costs or reduce patient visits. Why? Because today’s payment model financially rewards doctors and hospitals for the volume and cost of services they provide — not the quality of outcomes they achieve.

Until our payment model moves from fee-for-service to “pay-for-value,” some of the most effective technological solutions will be hard to sell.

3. Physicians are reluctant to show patients their medical information

Prior to the modern electronic health record (EHR), common wisdom was that doctors owned the medical information contained in a patient’s chart.

It made sense at the time. With only one copy of the medical record on hand, the safest place for it was the chart room located in the back of the doctor’s office.

Many doctors believed it was necessary to keep it out of the hands of patients, worrying the information could be harmful if read.

Much has changed in the era of information technology and consumerism. More and more, patients object to the paternalism of the past – asserting their right to access to their own health records.

But now there’s new medical record problem arising. As computers and keyboards replace charts and pens in exam rooms across the country, technology is now the physical barrier between patients and physicians.

But computers don’t have to create distance.

Some doctors are flipping their computers around and using the health data on screen to educate patients. This transparency ensures the information is accurate. It invites patients to participate more closely in their own treatment plans.

Still, today’s exam-room computers are clunky. Physicians would relish a more user-friendly tablet, capable of rapid data entry and mobility. And patients want access to their health data beyond the doctor’s office. Entrepreneurs who can address both of these needs will find an eager market.

4. Technology slows down many physicians

For the average physician, entering data into an EHR takes longer than keeping a paper record.

The problem isn’t just the time it takes to type but also the structured format of the data entry. It simply takes more time when the application prevents physicians from skipping steps or leaving out clinical details.

Frustrating as it may be for doctors, the added information reduces the risks of medical error, avoids redundant testing, and facilitates easier access to test results. But the benefits to the patient are clear, even when the technology adds time for the physician.

Just think, an EHR can prompt surgeons to ask patients about drug allergies as part of their medical history. Using this information, an EHR app can trigger an alert should the doctor accidentally try to order an antibiotic the patient is allergic to.

Physicians like to assume they’d never make such a mistake. Science proves otherwise. Some estimate the rate of drug errors by doctors has jumped 50 percent in recent years. Another study found 1 in 5 medications used by seniors are prescribed inappropriately.

Entrepreneurs can help physicians reduce the time needed for data entry by developing software applications that include macros and smart lists. Apps with alerts can help reduce medical errors.

But, of course, getting doctors to embrace these more effective approaches will be the next big challenge.

The doctor is likely to talk about the importance of the human touch or about how subjective the “art of medicine” is.

Yes, these are important factors in medicine. But providing personalized care in the future will require much more than that.

With the advent of gene sequencing and the exponential growth of medical information, physicians won’t be able to meet the unique medical requirements of individual patients without advanced IT systems.

As medical knowledge advances, the perceived rift between “high tech” and “high touch” is becoming a relic of the past.

Telling a patient he has cancer requires time, compassion and well-honed interpersonal skills. This is the traditional art of medicine. But figuring out the exact cancer treatment — given dozens of alternatives, the patient’s unique genetics and the many sub-types of each cancer – is more a matter of technology and science. Increasingly, treatment possibilities exceed the human mind.

In addition, when doctors lament modern medical practice becoming impersonal, they fail to understand how most people prefer to manage their lives.

In today’s era of consumerism, if you ask patients what they mean by personalized medical care, they’ll talk about being able to decide how, when and where they obtain information and treatment — just like they do when they travel or buy retail products and services.

Today’s busy people want to receive care through technologically enabled alternatives like video visits and secure email, rather than through the traditional office visit. And they’re frustrated by a health care system that refuses to accommodate them.

There’s a waiting market for entrepreneurs who can help people receive care virtually, without having to miss work or school — particularly if the solutions are less expensive.

To meet these preferences, entrepreneurs need to look further than at the hundreds of millions of smartphones resting in the hands or pockets of Americans today.

Overcoming these barriers

Across history, it often has been the next generation that figures out how best to use new technology. Health care may be no different.

But if hungry entrepreneurs don’t want to wait 10 or 15 years for the demographics to change, they would be smart to provide solutions that use currently available technology to solve patient’s problems in the simplest and least expensive ways.

Robert Pearl is a physician and CEO, The Permanente Medical Group. This article originally appeared on Forbes.com.

In a post two weeks ago, we were critical of some aspects of the JASON Task Force’s (JTF) Final Report on healthcare interoperability. Two members of the JTF reached out to us in order to clarify the intent of the report as it relates to EHRs and the use of a “public” API to help make healthcare applications more interoperable. During a long conversation, we had a chance to discuss the issues in detail. Following that discussion we took some time to reconsider our opinions.

We now have to agree that the JTF itself was not EHR vendor dominated and have corrected the previous post. The Task Force was comprised of a wide range of stakeholders including several providers. Unfortunately, however, the testimony the JTF received was overwhelmingly from HIT vendors, consultants, or their proxies. We doubt this was intentional, but simply the vendor community having a more vested interest in influencing the JTF. But it does lead us to the conclusion that it is incumbent upon the JTF to proactively solicit provider testimony before policymakers act on the recommendations of the JTF report.

Despite our long conversation with these members of the JTF, we still have a difference of opinion on one key issue: The central importance of the EHR with regards to public APIs and interoperability.

The original JASON Report points squarely at EHRs as the source of interoperability ills. It also called for EHRs to adopt the public API. By our count, the JTF Final Report uses three different ways to describe where the public API should sit: a “Data Sharing Network”, “CEHRT”, or “clinical and financial systems.” In our follow-up discussion, JTF representatives maintained that the intent to include EHRs is clear and that the task force struggled on this issue of how broad their mandate was.

The JTF decided to cast a broader net than just the JASON Report’s initial focus on EHRs. But they did not clarify an already complicated issue, nor did they unequivocally single out EHRs as where the need for a public API should begin. We think that their intention to include EHRs is sincere but maintain the position that the JTF should explicitly recommend that EHRs expose services and data with the public API. Without such clarity, the fuzzy language used in the JTF report could end up being adopted in future rule-making or legislation, creating the potential for uncertain outcomes.

Our Thesis:
Good, bad, or otherwise, the EHR is the dominant application supporting clinical workflows and the source of most patient healthcare data.

Every provider we have ever talked to says that improved patient care and more effective care coordination would be possible with better access to other providers’ EHRs. On the other hand, we have not talked to many providers who say that better patient care and better care coordination would be possible if only there was better access to other providers’ financial systems. The majority of providers have never heard of a Data Sharing Network (and no, we do not believe Direct can fill this bill) so the public API is pretty much dead in the water there as well – though most any HIE/CNM vendor worth their salt would welcome a public API.

So let’s be perfectly clear in the JTF report – if we want EHRs to adopt a public API, then let’s just say so rather than beating around the bush. To do otherwise sends the wrong message to the market – that EHRs are somehow not central to the interoperability problem.

The JASON Report created quite a fuss in the HIT marketplace as some screamed foul and others were encouraged that maybe, just maybe the JASON report may force movement to more open systems. To clear the air, the JASON Task Force (JTF) was formed to solicit industry feedback for policy makers. The JTF released their findings earlier this month.

The JASON Report was an AHRQ- and HHS-sponsored study of healthcare interoperability issues. Its basic conclusion was that the existing EHR-based HIT infrastructure should be superseded by something more open and amenable to use by other applications and across organizations. The JASON Report advocated radical solutions to the interoperability crisis: using MU3 to replace existing EHRs and requiring a uniform set of APIs for EHRs across the industry.

Vendor response was rapid and unified. HITPC appointed a task force representing stakeholders from across the industry (virtually all have been on other ONC workgroups, so somewhat cloistered) who worked with alacrity through the summer. The tone of vendor testimony before JTF reflected a level of alarm that contrasts sharply with HCO’s non-participation.

JTF and its vendor members have some legitimate beefs: the JASON Report is not exactly disinterested. It substantially reflects the view of the clinical research community which sees itself as the long-suffering victim of EHR intransigence. The JASON Report glosses over genuine, if crepuscular, progress in healthcare interoperability. Another point that we believe has not been made forcefully enough by EHR vendors is that they are constrained by their HCO customer’s ability to change. The organizational obstacles to healthcare data liquidity are significant and EHR vendors move only as fast as HCOs despite their claims to the reverse. However, we think that JTF is wrong to deflect attention away from the EHR-oriented APIs.

JTF’s proposed alternative to EHR supersession involves something it calls Data Sharing Networks (DSN). These are a rebranding of the HIE supplemented with a uniform set of APIs to support access to something never specified in much detail. JTF suggests that these APIs be based on the replacement to HL7 – FHIR.

Without doubt, FHIR represents a significant improvement over HL7 along multiple dimensions. But the idea that FHIR alone can cure the interoperability ills of healthcare is all smoke. Behind this smokescreen, EHR vendors are hoping that people eventually lose interest or stop talking about interoperability. With this bit of redirection, JTF has basically let the EHR vendors off the hook.

This begs the question: Where is the best place to have a uniform set of APIs reside, the DSN (HIE) or the EHR?

Our answer: Both!

The HIE is really a stopgap measure in the sense that discrete access to EHRs and other data sources across organizations via a uniform set of APIs and SOA will greatly reduce the need for an HIE. If applications could access all of a patient’s data directly from native data sources in different HCOs, there isn’t much point in maintaining separate and comprehensive CDRs at different sites in the overall healthcare system.

But rather than move in this direction, the JTF favors the politically powerful EHR vendors at the expense of the HIE vendor community.

No doubt creating a set of uniform APIs to EHRs would be costly. Upward and backward compatibility, a hallmark of every successful IT platform, requires deeper pockets than most EHR vendors can muster. But some EHR vendors are better positioned to support such APIs than others. Many hospital EHR vendors could make the investment. Smaller, community-focused, or client-server based EHR vendors and their customers though would struggle.

Our HIE research has shown – year after year – that data flows downhill from hospital to community. Hospital-based EHR data is valuable to community-based clinicians. It is also extremely valuable to those hospitals to ensure that physicians in a community get discharge summaries to minimize readmissions and associated penalties. Hospital-based EHRs are a good place to start with uniform APIs. The reality is that community-based EHR data could also be better used in hospital settings to facilitate care. This is especially true as we move away from fee for service to more risk-based payments models.

Unfortunately, facilitating data flows between community and hospitals is something we’ll be patching together with string, baling wire and duct tape for the duration. The JASON Report and subsequent JTF report have not moved the ball forward on this issue. It is our opinion that there is little that the policy folks in Washington D.C. can do with additional prescriptive meaningful use requirements. HHS would better serve the market by using financial incentives that promote healthcare organizations to demand better interoperability capabilities from their vendors as it is the customer that vendors really listen to, not D.C., policy wonks.